2.0 DHA
Performance Readiness Validation (PRV)/Performance Readiness Assessment
And Verification (PRAV)
During transition,
the incoming contractor’s performance readiness status regarding
claims processing will be subject to PRV/PRAV reviews as described
below.
2.1 Claims
Processing PRV
2.1.1 The contractor shall validate its ability to
process all TRICARE claim types with a minimum of a 98% accuracy
rate no later than 90 days prior to SHCD. Claims testing shall include
multiple claim types that represent a level of complexity involved
in claims for TRICARE benefits. Validation shall include claims
processing at the operational volume and stress testing at projected
claims volumes. The contractor shall provide validation results,
to include test scenarios used, to the Government within 10 days
following conclusion of the contractor’s validation.
2.1.2 The contractor
will validate its ability to provide timely and accurate responses
to beneficiary and provider claims customer service inquiries and
attest that they meet the following staffing requirements:
• Seventy-five
percent (75%) of beneficiary and provider claims customer service
staffing hired and trained on provider and beneficiary claims customer
service, including internal and external systems interfaces, no
later than 90 days prior to SHCD.
• Eighty-five (85%)
of beneficiary and provider claims customer service staffing hired
and trained on provider and beneficiary claims customer service,
including internal and external systems interfaces, no later than
60 days prior to SHCD.
• Ninety-five (95%)
of beneficiary and provider claims customer service staffing hired and
trained on provider and beneficiary claims customer service, including
internal and external systems interfaces, no later than 30 days
prior to SHCD.
2.1.3 The contractor shall validate
it can receive and utilize claims history file transfers from the outgoing
contractor no later than 14 calendar days following receipt of the
files from the outgoing contractor.
2.1.3.1 The contractor
shall include in its validation process a test of a statistically
valid number of records to ensure readability and usability of information.
Tests shall include accessibility to records, accuracy of data,
and the contractor’s ability to use the data to correctly to apply
TRICARE policy, such as time or episode limited benefits.
2.1.3.2 Results
must reach a minimum of 98% accuracy no later than 45 days prior
to SHCD. The contractor shall provide test scenarios as well as
testing results to the Government no later than 45 days prior to
SHCD.
2.1.4 Reimbursement rate system
applications validation.
2.1.4.1 The contractor
shall develop tests to ensure reimbursement rate system applications
are correctly loaded and functioning properly. Areas tested shall
include negotiated network discount rates, non-network rates, and
specific reimbursement rates as required by policy (Example: Sole Community
Hospitals (SCHs), Low/High-Volume Mental Health Facilities, Partial
Hospitalization facilities, etc.). Validation shall include demonstrating
a variety of claims scenarios where reimbursement rate system applications
are applied.
2.1.4.2 The contractor
shall complete its reimbursement rate system validation no later
than 90 days prior to SHCD and provide the Government with validation
results, to include test case scenarios used, within 10 days following
conclusion of the contractor’s validation. If, after review, the Government
finds the contractor’s testing or outcomes are deficient, the contractor
shall submit a detailed mitigation plan no later than 14 calendar
days following receipt of the Government’s findings.
2.1.5 Validation
that the claims processing system differentiates between beneficiary
categories.
2.1.5.1 The contractor shall validate that its claims
processing system clearly identifies and appropriately differentiates
between beneficiary categories to facilitate claims processing accuracy
by testing a multitude of scenarios with different beneficiary categories
(as specified in the TRICARE Systems Manual (TSM)) to ensure appropriate
application of cost-shares, co-pays and rates.
2.1.5.2 The contractor
shall complete its system testing no later than 90 days prior to
SHCD with a 95% accuracy rate. The contractor shall complete its
claims processing system differentiation validation no later than
90 days prior to SHCD and provide the Government with validation
results, to include test case scenarios used, within 10 days following
conclusion of the contractor’s validation. If, after review, the
Government finds the contractor’s testing or outcomes are deficient,
the contractor shall submit a detailed mitigation plan no later
than 10 business days following receipt of the Government’s findings.
2.1.6 Claims
and TED records systems interface validation.
2.1.6.1 The contractor’s
validation shall include developing and executing tests to validate
its claims processing system (Defense Enrollment Eligibility Reporting
System (DEERS)/Defense Manpower Data Center (DMDC), Referrals/Authorizations,
etc.) can process claims in accordance with TRICARE timeliness and
accuracy standards. The contractor’s validation methodology shall
aggressively test system connectivity of its claims processing system
with both internal and external systems in order to ensure timely
and accurate processing of claims. Testing shall include responses
consistent with production volume as well as stress testing.
2.1.6.2 The contractor
shall complete its system testing with Government interfaces and
attest to the contractor’s ability to apply information received
from DEERS/DMDC (beneficiary eligibility, catastrophic cap (CATCAP),
family association, etc.) in a timely and accurate manner, and that
they are able to successfully process TEDs prior to moving to a
production environment. The contractor shall provide its system
test plan to the Government at contract award. Initial testing shall
begin no later than three months following contract award, and the
contractor’s claims/TEDs system interfaces shall be fully operational
no later than 60 days prior to SHCD.
2.1.7 Validation
that the contractor’s claims processing system accurately and appropriately applies
referrals and authorizations.
2.1.7.1 The contractor’s
validation shall include demonstrate its ability to integrate its
referrals and claims systems with the direct care system through
CHCS and/or other Military Treatment Facility (MTF)/Enhanced Multi-Service
Market (eMSM). The contractor shall validate that its claims processing system
is able to accurately and appropriately transfer and apply information.
The contractor shall attest to its ability to achieve a minimum
of 98% accuracy in receiving and applying referrals/authorizations
information received from MTFs/eMSMs and use this information to
correctly process claims.
2.1.7.2 Communication
interface trustworthiness determinations between the contractor
and MTFs/eMSMs must be obtained and operational no later than 120
days prior to the SHCD and all validation testing shall be completed
no later than 60 days prior to SHCD.
2.2 Claims Processing
PRAV
2.2.1 The contractor shall comply with the Government’s
approach for assessment and verification of the contractor’s performance
readiness regarding claims processing as described above. If, after
review, the Government finds the contractor’s performance readiness
for claims processing to be deficient, the contractor must submit
a detailed mitigation plan no later than 10 days business days following
the Government’s findings.
2.2.2 Specific PRAV activities,
assessment techniques, and performance readiness thresholds will be
identified by the Government during the Transition Specification
Meeting.